Healthcare Provider Details

I. General information

NPI: 1992144422
Provider Name (Legal Business Name): TYLER ANDERSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 SELSA RD STE 7
INDEPENDENCE MO
64057-1712
US

IV. Provider business mailing address

1432 E HUGHS
BOLIVAR MO
65613-2397
US

V. Phone/Fax

Practice location:
  • Phone: 816-795-0434
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number2013017749
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: